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1 MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF I. Requirements for Prior Authorization of Tysabri A. Prescriptions That Require Prior Authorization All prescriptions for Tysabri must be prior authorized. B. Review of Documentation for Medical Necessity In evaluating a request for prior authorization of a prescription for Tysabri, determination of whether the requested prescription is medically necessary will take into account whether: 1. The recipient: a. Has a diagnosis of relapsing Multiple Sclerosis (MS) b. Is 18 years of age or older c. Is not receiving chronic immunosuppressant or immunomodulatory therapy d. Has a documented history of contraindication, intolerance, or therapeutic failure of alternative MS therapies as follows: i. Copaxone ii. Avonex iii. Rebif iv. Betaseron e. Is enrolled in the Multiple Sclerosis Tysabri Outreach Unified Commitment to Health (MS TOUCH) Prescribing Program, a mandatory registry program f. Had a Magnetic Resonance Imaging (MRI) scan prior to initiating Tysabri therapy to help differentiate MS symptoms from progressive multifocal leukoencephalopathy (PML) 1

2 MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF g. Had baseline testing for anti-jc virus antibodies h. For requests for prior authorization of renewals of prescriptions for Tysabri that were previously approved, whether the recipient s Multiple Sclerosis improved or stabilized as documented by the prescriber i. If baseline testing for anti-jc virus was negative, had repeat testing for anti-jc virus antibodies 2. The recipient: a. Has a diagnosis of moderately to severely active Crohn s Disease with inflammation b. Is 18 years of age or older c. Is not receiving chronic immunosuppressant or immunomodulatory therapy d. Has a documented history of therapeutic failure of a trial (see chart below for trial timeframes) of, or contraindication or intolerance of the following conventional therapies: i. Aminosalicylates ii. Immunomodulators Aminosalicylates Mesalamine Sulfazalazine 2

3 MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF Immunomodulators Azathioprine Methotrexate 6-Mercaptopurine e. Has a documented history of: i. Therapeutic failure of a trial (see chart below for trial timeframes) of preferred Inhibitors of TNF- α that are in the Cytokine and CAM Antagonist class of drugs on the Preferred Drug List ii. Contraindication or intolerance to preferred Inhibitors of TNF- α that are in the Cytokine and CAM Antagonist class of drugs on the Preferred Drug List TNF- α Inhibitor Cimzia Humira Remicade 6 weeks 10 weeks f. Is enrolled in the Crohn s Disease-Tysabri Outreach Unified Commitment to Health Prescribing Program (CD TOUCH) g. Had baseline testing for anti-jc virus antibodies 3. For a renewal of a request for prior authorization that was previously approved, whether a. The recipient has experienced therapeutic benefit by of therapy induction 3

4 MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF b. The recipient can discontinue concomitant corticosteroid use within 6 months of starting therapy c. If baseline testing for anti-jc virus was negative, had repeat testing for anti-jc virus antibodies NOTE: Requests for renewal of the prescription will not be approved if the recipient requires additional steroid use that exceeds in a calendar year to control their Crohn s disease. 4. Does not meet the clinical review guidelines listed above, but in the professional judgment of the physician reviewer, the services are medically necessary to meet the medical needs of the recipient. C. Clinical Review Process Prior authorization personnel will review the request for prior authorization and apply the clinical guidelines in Section B. above, to assess the medical necessity of the request for a prescription for Tysabri. If the guidelines in Section B. are met, the reviewer will prior authorize the prescription. If the guidelines are not met, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. Such a request for prior authorization will be approved when, in the professional judgment of the physician reviewer, the service is medically necessary to meet the medical needs of the recipient. D. Long Term Therapy The Department will limit authorization of Tysabri as follows: 1. For a diagnosis of moderately to severely active Crohn s Disease with inflammation: a. Initial requests will be limited to: i. Three (3) months if the recipient is not taking chronic oral corticosteroids while starting Tysabri 4

5 MEDICAL ASSISTANCE HBOOK PRI AUTHIZATION OF E. References ii. Six (6) months if the recipient is on chronic oral corticosteroids while starting Tysabri to allow tapering of the corticosteroids b. Requests for renewals of prescriptions that were previously approved will be approved for a period of 12 months. 2. For a diagnosis of relapsing Multiple Sclerosis (MS): a. Initial requests will be limited to six (6) months b. Requests for renewals of prescriptions that were previously approved will be approved for a period of 12 months 1. Tysabri package insert. Biogen Idec Inc, Goodin, DS et.al. Assessment: the use of natalizumab (Tysabri) for the treatment of multiple sclerosis (an evidence-based review). Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology 2008;71; Goodin DS, et.al..disease modifying therapies in multiple sclerosis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology and the MS Council for Clinical Practice Guidelines Neurology 2002 Jan 22;58(2): Farrell, RJ et.al. Overview of the management of Crohn s disease in Adults UpToDate ONLINE. Updated March 11, Accessed August 19, Olek, MJ. Treatment of relapsing-remitting multiple sclerosis in adults UpToDate ONLINE. Updated June 8, Accessed August 19, Macdermott R.P. Immunomodulator therapy in Crohn s disease UpToDate ONLINE. Updated June 2, Accessed August 19,

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